Journal of Mind and Medical Sciences

Volume 7 Issue 1 Article 17

2020

Therapeutic approach for Amyand’s ; a case report

Sorin Berbece DUNĂREA DE JOS UNIVERSITY OF GALAȚI, FACULTY OF MEDICINE AND PHARMACY, DEPARTMENT OF MORPHOLOGICAL SCIENCES, GALAȚI, ROMANIA

Valeriu Ardeleanu OVIDIUS UNIVERSITY, FACULTY OF MEDICINE AND PHARMACY, CONSTANȚA, ROMANIA

Vlad Denis Constantin CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, BUCHAREST, ROMANIA

Ioana Paunica NATIONAL INSTITUTE OF DIABETES, NUTRITION AND METABOLIC DISEASES, BUCUREȘTI, ROMÂNIA

Alexandra Toma DUNĂREA DE JOS UNIVERSITY OF GALAȚI, FACULTY OF MEDICINE AND PHARMACY, DEPARTMENT OF MORPHOLOGICAL SCIENCES, GALAȚI, ROMANIA

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Recommended Citation Berbece, Sorin; Ardeleanu, Valeriu; Constantin, Vlad Denis; Paunica, Ioana; and Toma, Alexandra (2020) "Therapeutic approach for Amyand’s hernia; a case report," Journal of Mind and Medical Sciences: Vol. 7 : Iss. 1 , Article 17. DOI: 10.22543/7674.71.P105109 Available at: https://scholar.valpo.edu/jmms/vol7/iss1/17

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Journal of Mind and Medical Sciences

https://scholar.valpo.edu/jmms/ https://proscholar.org/jmms/ I S S N : 2 3 9 2 - 7 6 7 4

Therapeutic approach for Amyand’s hernia; a case report

1 2-5 6 7 Sorin Berbece , Valeriu Ardeleanu , Vlad Denis Constantin , Ioana Paunica , Alexandra Toma1,2

1 DUNĂREA DE JOS UNIVERSITY OF GALAȚI, FACULTY OF MEDICINE AND PHARMACY, DEPARTMENT OF MORPHOLOGICAL SCIENCES, GALAȚI, ROMANIA 2 C.F.R. HOSPITAL OF GALAȚI, DEPARTMENT OF SURGERY, GALAȚI, ROMANIA 3 DUNĂREA DE JOS UNIVERSITY OF GALAȚI, DEPARTMENT OF KINETOTHERAPY, GALAȚI, ROMANIA 4 OVIDIUS UNIVERSITY, FACULTY OF MEDICINE AND PHARMACY, CONSTANȚA, ROMANIA 5 ARESTETIC CLINIC OF GALAȚI, GALAȚI, ROMANIA 6 CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, BUCHAREST, ROMANIA 7 NATIONAL INSTITUTE OF DIABETES, NUTRITION AND METABOLIC DISEASES, BUCUREȘTI, ROMÂNIA

ABSTRACT

In very few cases stated in the literature, the vermiform appendix might be Category: Case Report contained in a hernial sac. This distinctive pathology is described as Received: August 10, 2019 Amyand's hernia and has the very small occurrence of about 1%. We report Accepted: October 02, 2019 the case of a 62-year-old man that presented for a reducible tumoral mass located in the right inguinal region. Amyand’s hernia was the intraoperative Keywords: diagnostic. We performed hernioplasty (using the Lichtenstein tension-free Amyand`s hernia, , hernia sac, hernia surgery, hernioplasty, tension-free mesh mesh repair with a composite mesh) without . This case matches the type 1 Lossanoff and Basson’s classification and has *Corresponding author: no facile management. Due to the clinical specificities of each case that Alexandra Toma, Dunărea de Jos University of Galați, presents with defining features of an Amyand’s hernia, surgical management Faculty of Medicine and Pharmacy, Department of Morphological Sciences, Galați, Romania depends on the recommendations stated in the literature, as well as the E-mail: [email protected] surgeon’s judgment based on experience.

Introduction imaging tests like ultrasonography and computed tomography. Sometimes, the clinical findings or even In 1735 Claudius Amyand - a noted surgeon of that abdominal ultrasonography can lead to a misdiagnosis, as period - practiced appendectomy on an 11-year-old male there are similarities between symptoms for Amyand’s patient, diagnosed preoperatively with a right inguinal hernia and other conditions, including a cecum/ ascendant hernia [1]. The patient survived, but the hernia pathology colon cancer, lymph metastasis from , or other reoccurred. The eponym Amyand`s hernia refers to a abdominal cancer [5-12]. The intraoperative diagnosis is condition characterized by the protrusion of the cecal the most frequent way of carrying out a differential appendix in the inguinal hernia sac. In such cases, the diagnosis. appendix may be normal, inflamed, or even perforated. While the physiopathology remains imprecise, the Case presentation literature notes that the vermiform appendix herniates through the processus vaginalis [2]. It is one of the rarest A 62-year-old male presented to our surgery forms of inguinal with an incidence varying department complaining of an enlarging inguinal mass between 0.19 – 1.7%, most often encountered in male located in the right groin, accompanied by pain in the right patients [3, 4]. inguinal area. Patients usually present to the hospital with signs and Based on anamnesis, he stated that the mass appeared symptoms that are no different from those encountered in for the first time in a very small area of the right inguinal a patient diagnosed with an inguinal hernia. Amyand`s region, about three years ago. The groin mass increased in hernia can be diagnosed preoperatively using simple size over time, with prolonged standing or even walking,

To cite this article: Sorin Berbece, Valeriu Ardeleanu, Vlad Denis Constantin, Ioana Paunica, Alexandra Toma. Therapeutic approach for Amyand’s hernia; a case report. J Mind Med Sci. 2020; 7(1): 105-109. DOI: 10.22543/7674.71.P105109 Sorin Berbece et al. and finally, when the patient was doing the most normal neither inflamed nor showed other signs of pathology. The and low demanding house chores. The patient had no intervention continued with herniorrhaphy (using the retro history of chronic diseases or any associated comorbidities. funicular procedure), followed by hernioplasty using the In the last few days, he had been self-medicating with Lichtenstein tension-free mesh repair. The repair mesh was ibuprofen. a composite polypropylene mesh. Upon physical examination, in the right inguinal area, we discovered that the region was deformed by a non- erythematous, non-fluctuant, slightly reluctant to fell, and mobile mass, with a diameter of about 4 cm x 5 cm. There were no signs of intestinal obstruction. We could also palpate the right inguinal foramen that was much weakened. Laboratory test values showed normal limits; no additional imaging tests were performed due to patient history of uncomplicated inguinal hernia. We scheduled the patient for inguinal hernia surgery within a few days after admission. On the day of surgery, the patient was transferred to the operating room, and the anesthesiology team opted for spinal anesthesia. Preoperative disinfection used a Figure 2. Vermiform appendix in the hernial sac povidone-iodine solution. After careful draping of the patient, an incision was performed in the right inguinal The postoperative period followed with no particular region; within the , an oblique hernial sac events or complications. The patient showed no sign of was revealed. After dissection of the spermatic cord infection or inflammation and was able to move (slightly difficult due to a chronic process that resulted in independently. The patient also quickly regained normal multiple adhesions), we completed isolation of the hernial intestinal transit (i.e., he was able to feed normally). The sac. surgical site evolved favorably so that he was discharged After opening the sac, we encountered a lipoma (an on the third postoperative day. At discharge, we advised the patient to avoid even small and insignificant usual finding) and caecum and vermiform appendix that movements or household tasks for about three months, so represent rare findings in an inguinal hernia sac (Figure 1, that hernia pathology would not recur. 2). Discussions Amyand`s hernia is a rare form of inguinal hernia, with low incidence and often difficulty to diagnosis. It is defined as the presence of the cecal appendix in a groin hernia, with or without appendicitis [3]. Garengeot, in 1731 [14], was the first to describe the occurrence of a non-inflamed vermiform appendix in a direct inguinal hernia sac. The name of the particular type of inguinal hernia described in this case study is derived from the French surgeon, Claudius Amyand, who was the first to perform an appendectomy ion an 11-year-old patient with a perforated appendix within the inguinal

hernial sac. Later, the Garengeot name was used to Figure 1. The content of the hernia sac describe the type of that contains appendix The intraoperative diagnosis was established based on in the hernial sac, while Amyand`s hernia defines the the findings within the content of the hernial sac. Based on inguinal hernia with vermiform appendix present in the the international diagnostic criteria for this pathology, we sac. classified it as a type 1 Amyand’s hernia [13]. We did not Garengeot and Amyand are specific types of low perform an appendectomy because the appendix was incidence hernias. The presence of a cecal appendix in the 106 Therapeutic approach for Amyand’s hernia hernia sac is reported in about 1% (0.19 - 1.7%) of all cases appendix by using multi-level reconstruction of the of inguinal hernias [3,4]. The incidence of such types of examined structures. hernias containing a perforated appendix is even lower Surgical treatment must take into account two (0.13%), but the prognosis for this pathology is quite important aspects: the contents of the hernia sac (and the severe, with severe abdominal sepsis and even high condition of the contained vermiform appendix), the mortality (10-30%) [15]. The incidence of the disease is necessity of restoring the abdominal content in its natural greater in men than women, with the prevalence of locating place, followed by a specific hernia surgical procedure the hernia on the right side, a consequence of the normal tailored to the patient's needs. anatomical position of the cecal appendix on the right side. The first classification of Amyand hernias, taking into Cases of Amyand`s hernia have also been reported on the account the type of hernia pathology, the associated left side of the abdomen, resulting from situs inversus, manifestations, and the most advised surgical intestinal malrotation, or mobile caecum [16-18]. management, was generated by Lossanoff and Basson in The development of any type of hernia (common or 2008. They identified and defined four types: one with a rare) in the groin region does not usually produce a normal appendix, and three types with inflamed appendix, significant change in the quality of the patients' life during and the last with associated conditions (Table 1). the initial stages, which could explain the late presentation for medical investigation. In initial and sometimes even Table 1. Lossanoff – Basson classification after Morales – Cardenas complicated forms, inguinal hernias that include the vermiform appendix in the sac are often asymptomatic, Classification Description Management with symptoms appearing only once the appendix is inflamed or perforated. Even in such cases, the symptoms Type I Normal appendix Hernioraphy, followed for which the patient presents to the hospital are similar to enclosed within the by mesh hernioplasty incarcerated hernias: local erythema, swelling determined sac of an inguinal (free of choice: by an immobile mass, pain in the lower right abdominal hernia appendectomy in young patients) quadrant, accompanied by nausea and vomiting. Clinical manifestations, sometimes non-specific and Type II Symptoms of acute Perform an insidious, often lead to difficulties in setting up a positive appendicitis, no appendectomy followed differential diagnosis, which may lead to the late evidence of by a hernioplasty without establishment of the disease-specific therapeutic option. abdominal sepsis a mesh Children present more obvious symptoms and can mimic Type III Symptoms of acute Perform an even acute scrotum [19]. In adults, the evolution of the appendicitis, with appendectomy followed disease usually has a gradual history, with patients often evidence of by a hernioplasty without presenting to the hospital after years from the onset of the abdominal sepsis a mesh pathology and reporting episodes of expansion followed by Type IV Symptoms of acute Perform an reduction of the pseudo tumoral inguinal mass until appendicitis, with appendectomy followed incarceration of the hernia sac occurs. affiliated by a hernioplasty without From the perspective of associated pathology, abdominal a mesh. Subsequent - Amyand`s hernia can present as various clinical forms, pathology outside managing the affiliated the hernial sac pathology, after the initial from the presence in the hernia sac of the normal procedure vermiform appendix to an inflamed appendix, leading finally to a necrotic or even perforated appendix [20, 21]. There is general agreement regarding the surgical Some cases of associated tumors have also been described procedure for types III and IV, which consists of in the literature [22-24]. appendectomy and primary , avoiding use of Imaging tests that include ultrasonography and the mesh [4]. However, controversy surrounds surgical computer tomography might show a tubular form structure treatment for types I and II. There are case reports of a non- originating at the caecum and extending into the hernial inflamed appendix present in the herniated sac, but with sac. A normal appendix cannot be easily visualized while fibrous adhesions to it, which makes it impossible to performing ultrasonography, and this may lead to a release safely and thus required appendectomy [4, 13]. misdiagnosis of Amyand`s hernia. On the other hand, Several case reports of Amyand`s hernia have taken a computer tomography can identify not only the structure laparoscopic approach, with normal vermiform appendix but also the length and appearance of the vermiform contained in the hernia sac, or even Amyand`s hernia 107 Sorin Berbece et al. presented with acute appendicitis [14,25]. Some cases of Medica (Hradec Kralove). 2017; 60(3):131–134. Amyand`s hernia have been resolved by using robotic doi:10.14712/18059694.2018.7. surgery [26-28], which may involve a minimally invasive 4. Shaban Y, Elkbuli A, McKenney M, Boneva D. approach. Amyand's hernia: A case report and review of the literature. Int J Surg Case Rep. 2018; 47:92–96. doi: Highlights 10.1016/j.ijscr.2018.04.034. ✓ Amyand’s hernia is a rare form of vermiform appendix 5. Suceveanu AI, Pantea Stoian A, Parepa IR, Voinea C, hernia. Hainarosie R, Manuc D, Nitipir C, Mazilu L, ✓ Surgical treatment of Amyand’s hernia depends on the Suceveanu AP. Gut Microbiota Patterns in Obese and contents of the hernia sac Type 2 Diabetes (T2D) Patients from Romanian Black Sea Coast Region. Rev Chim (Bucharest). 2018; 69(8): Conclusions 2260-67. Amyand`s hernia is a very rare hernia pathology 6. Suceveanu AI, Mazilu L, Nitipir C, Pantea Stoian A, represented by the protrusion of the vermiform appendix in Parepa I, Voinea C, Suceveanu AP. Diabetes Mellitus the hernia sac. raise the risk for Interval Colorectal Cancer and Studies suggest the need for adequate management of Advanced Adenomas. Rev Chim (Bucharest). 2019; Amyand`s hernia, in close connection with intraoperative 70(5):1808-11. observations. Most surgeons choose not to remove the 7. Tuta LA, Iorga I, Azis O, Voinea F. End-of-life Care in appendix if they conclude that it is within normal characteristics. Some surgeons prefer appendectomy for all Erderly Patients with End-Stage Renal Disease – Amyand`s hernias situated in the left inguinal region, while Ethical and Clinical Issues. 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